Is topical Voltaren (diclofenac) gel safe for patients with Chronic Kidney Disease (CKD) and autoimmune hepatitis?

From the FDA Drug Label

The renal effects of diclofenac sodium topical solution may hasten the progression of renal dysfunction in patients with preexisting renal disease Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of diclofenac sodium topical solution Avoid the use of diclofenac sodium topical solution in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function.

Topical Voltaren (diclofenac) gel safety for CKD and autoimmune hepatitis patients:

• Chronic Kidney Disease (CKD): The use of topical diclofenac may worsen renal function in patients with preexisting renal disease.
• Autoimmune Hepatitis: While there is a warning about hepatotoxicity, the label does not provide specific guidance on the use of topical diclofenac in patients with autoimmune hepatitis.
• Key Considerations:
  • Monitor renal function in patients with CKD.
  • Avoid use in patients with advanced renal disease unless benefits outweigh risks.
  • Exercise caution when prescribing diclofenac to patients with hepatic impairment.
  • Monitor patients for signs of worsening renal function or hepatotoxicity. 1 1 1

From the Research

Topical Voltaren (diclofenac) gel should be used with caution in patients with Chronic Kidney Disease (CKD) and autoimmune hepatitis, and only under medical supervision. While topical NSAIDs like diclofenac gel have significantly lower systemic absorption compared to oral forms (typically less than 10% reaches the bloodstream), there is still some risk for patients with these conditions. For patients with CKD, even small amounts of systemic diclofenac could potentially worsen kidney function, as NSAIDs reduce prostaglandins that help maintain kidney blood flow, as noted in a study published in 2021 2. Similarly, in autoimmune hepatitis, any systemic absorption might potentially stress an already compromised liver.

Some key considerations for the use of topical NSAIDs in patients with CKD include:

• The potential for nephrotoxicity, which can be mitigated by using the lowest effective dose for the shortest duration possible 3
• The importance of monitoring kidney function during treatment, as changes in kidney function can occur even with topical use 2
• The need to avoid using the gel on broken or irritated skin, which could increase absorption and exacerbate potential side effects

Alternative pain management strategies, such as acetaminophen (if liver function permits), physical therapy, or other non-pharmacological approaches, might be safer options for these patients. It is essential to weigh the potential benefits of topical Voltaren gel against the potential risks and to closely monitor patients for any adverse effects, particularly those related to kidney and liver function. A study from 2020 highlighted the importance of careful consideration of risk factors when using NSAIDs in patients with CKD 3.

In terms of specific guidance, patients with CKD and autoimmune hepatitis should:

• Use the smallest effective amount of topical Voltaren gel
• Apply the gel to small body areas
• Use the gel for the shortest duration possible
• Avoid using the gel on broken or irritated skin
• Be closely monitored for changes in kidney and liver function during treatment.